The “failures” of an NHS trust contributed to the death of a father-of-three who committed suicide, an inquest concluded today.

The body of Peter Daniel Usher, 39, of North Street, Romford, was found at Bower Park Academy on January 21, two weeks after his family reported him missing.

Coroner Nadia Persaud gave a narrative verdict this morning at Walthamstow Coroner’s Court, in line with conclusions made about the care provided by staff at Goodmayes Hospital, one of the health centres run by the North East London Foundation Trust (Nelft), where Mr Usher was last treated.

“I found in the evidence that I have heard, too much attention was being paid to his presentation at the time of the assessment”, she said.

“Doctors must consider all relevant clinical information.

“The information was history from the family, a summary from the GP, further details of what happened at Bower Park school and details from the paramedics that he wanted to kill himself.

“I found that this was not complied with.

“On the basis of the above, I feel that the failures of Goodmayes contributed to his death.”

Ms Persaud told the inquest a report will be put together summarising suggestions on how to improve mental health provision at Nelft. Chief executive of Nelft John Brouder said: “We would like to reiterate the unreserved apologies we have previously made to Peter

Daniel Usher’s family for the shortcomings in care during his admission to the Section 136 Suite at Goodmayes Hospital on December 28 2015, and wish, again, to offer our sincere condolences.

“The trust’s internal investigation and the coroner’s inquest investigation identified key shortcomings and these findings have already led to important changes in our systems and practice.

The trust is thoroughly examining the findings and conclusion of the inquest to continue learning from this tragic case and implement additional changes as required.

“We realise that these steps cannot ever make up for the loss of Mr Usher, but we hope that the important changes we are making provide some reassurance to everyone affected as to the very considerable efforts the Trust and its staff have made to learn from this tragic case and improve our systems and practices.”

“The time to repair the roof is when the sun is shining,” so the saying goes. So if some warm weather is making your conservatory uninhabitable, think about replacing its roof with a flat one and adding a roof lantern instead.

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